Warning: count(): Parameter must be an array or an object that implements Countable in /home/skhch0/public_html/medical/libraries/cms/application/cms.php on line 460

Warning: count(): Parameter must be an array or an object that implements Countable in /home/skhch0/public_html/medical/libraries/cms/application/cms.php on line 460
按編號分類

Case 21-40

cxr7
ct1_31
ct2_03
ct3_17
40歲男性,主訴咳嗽,CXR及CT如上。

  • 這是一個bronchogenic cyst的case。

  • CXR及CT可以發現一個well-defined tumor,打了contrast medium之後tumor內之影像密度沒變,但是有一個很明顯的wall出現,因此可判定是cystic lesion。

  • 手術後的病理結果為bronchogenic cyst。

  • 以下是有關bronchogenic cyst的簡單介紹:

  • Clinical Sx:
    Most of the patients are asymptomatic and the diagnosis of bronchogenic cyst is an incidental finding, especially in cases of mediastinal bronchogenic cysts. Pulmonary bronchogenic cysts, however, may become infected and present with cough and fever. Male predominance is reported.

  • Etiology/Pathophysiology:
    Bronchogenic cysts result from abnormal budding or branching of the ventral diverticulum of the forgut or tracheobronchial tree during embryological development.

  • Pathology:
    These thin walled cysts are lined with respiratory epithelium and filled with protein rich, mucoid material.

  • Imaging:

  • Classic radiographic manifestations are a well-defined round or oval mass commonly located just inferiorly to the carina.  
    CT demonstrates a sharply defined, smoothly marginated, homogeneous mass. These masses are usually of water density but may be associated with higher CT numbers when the internal contents are mucoid.
    Similarly, T1 weighted MR images may demonstrate a high intensity due to protein rich contents or the MR signal may be indicative of water.

  • DDx:
    Middle mediastinal lesions.
    Lymphadenopathy
    Vascular structures
    Tumors

Mycotic1
Mycotic2
74歲男性病患,因發燒住院,經治療兩週後所追蹤的CXR有以上的變化,病患同時出現聲音撒啞的症狀。

  • 這是一個mycotic aneurysm的case,blood culture證實為salmonella infection。。
  • CXR顯示兩週內病患的上縱隔腔有明顯變寬且trachea有被推擠到右側去的情形,這時必需要考慮血管性病變或外傷性病變。因病人臨床上有sepsis的表現,因此mycotic aneurysm首先要列入考慮。
  • 其他尚須作鑑別診斷的有aortic dissection, aortic transection, acute mediastinitis (e.g. esophageal perforation)等。
Mycotic3

Azygous

17歲女性病患,體檢時發現X光異常而轉至胸腔科門診求診,無特別症狀,CXR如上。

  • 這一題的答案是azygos fissure,是accessory fissure的一種,約在0.5-1%的正常人會看得到。之所以叫azygos fissure的原因是因它的下緣連接著azygos vein。
  • Azygos fissure是因azygous vein在胚胎期自胸壁移動至胸腔內的tracheobronchial angle不完全所致。它和正常的pleura一樣含有visceral pleura和parietal pleura,不過內外各有兩層,因此一共有四層pleura。
  • Azygos fissure以前叫azygos lobe,因為Azygos fissure將一部份的肺自肺上葉分離出來,但因它的血流供應是來自apical segment的分枝(有時也會來自posterior segment的分枝),因此不具備成為一個lobe的條件,故azygos lobe是一個錯誤的命名。
  • Azygos fissure幾乎都在右側,但也有些人報告過左側的azygos fissure,在左側者,它的下緣所接的是superior intercostal vein。
  • 有時要和achalasia作鑑別診斷,一般achlasia會有air-fluid level,而azygous fissure則無。

focus

thymoma1
thymoma-lat
57歲女性,無明顯症狀,體檢時發現X光有異常被轉至胸腔科門診。

  • 這是一個thymoma的case。
  • CXR可發現左側hilar處有一個陰影,因為和aorta及pulmonary artery之間的界線是清楚的,由此可推斷應是前縱隔腔的病灶。
  • Lateral view和CT上顯示anterior mediastinum有一腫塊。
  • Anterior mediastinal tumor之鑑別診斷有3T+1L (Thyroid, Thymoma, Teratoma, Lymphoma)。
  • 約有15%的MG病人會合併有thymoma,而thymoma的病人約有35%會有MG的症狀。
thymoma-f
thymoma-ct2
pa
45歲男性病患,主訴數個月前開始感覺呼吸困難,CXR如上。

  • 這是一個intrathoracic goiter的case。
  • CXR上可發現trachea有明顯的左偏,因此可判斷是 right side anterior mediastinal lesion。
  • 再複習一次,anterior mediastinal mass的鑑別診斷有3T+1L。若一個anterior mediastinal lesion的上緣是從脖子開始延伸下來,則要先考慮是thyroid lesion。
  • Intrathoracic thyroid 的特徵:
    • Well defined
    • Spherical or lobular
    • Trachea compression
    • 有時會跑到trachea後面,食道前面(1/4),但不會跑到食道後面
    • 有鈣化通常是良性,但些時惡性腫瘤也會有鈣化,惡性腫瘤的鈣化通常是 fine dots calcification。
    • 腫瘤會從脖子一直連下來
    • Multinodular goiter 會有cystic component
    • CXR上的density會比muscle高

focus


Warning: count(): Parameter must be an array or an object that implements Countable in /home/skhch0/public_html/medical/libraries/cms/application/cms.php on line 460